Association of Parental Status and Gender With Burden of Multidisciplinary Tumor Boards Among Oncology Physicians

Key Points Question What is the burden of tumor boards among oncology physicians? Findings In this survey study of tumor board burden, identifying as a woman or a parent was associated with a significantly higher level of burden from early morning and/or late evening tumor boards. Having 2 or more children, attending 3 or more hours per week of tumor boards, or being a radiologist or pathologist was associated with a significantly higher level of burden overall. Meaning This study suggests that future strategies should aim to decrease tumor board burden, particularly the disparate burden on parents, women, and/or specific specialists.


Introduction
Tumor boards are multidisciplinary team meetings focused on clinical assessment and decisionmaking in cancer care.2][3] Given the specialized expertise tumor boards require, there can be significant logistical and administrative challenges in bringing together representatives from all disciplines. 1gnificant time and effort are spent in the preparation and running of tumor boards. 3Tumor boards are often held weekly or biweekly, and many physicians, especially those who treat multiple disease sites, may attend several tumor boards per week.This commitment can include time for both preparation and attendance, particularly if they are leaders of the tumor board and/or responsible for preparing the data, as well as commuting for in-person participation.Several obstacles to tumor board effectiveness have been reported, including poor attendance due to time constraints, unprotected meeting times, and lack of administrative support and funding. 3Moreover, tumor board meetings may variably be held at early and/or late hours.However, data describing this practice are lacking.
Although there is growing research investigating the association between parenthood and physician work-life balance 4,5 ; the contribution of increased, uncompensated administrative burden or excessive clerical work; and work-home conflicts with physician burnout, 6 there is a paucity of data evaluating tumor board-associated burden among oncology physicians.We hypothesize that the burden of tumor boards is readily detectable and that early morning and/or late evening tumor board meetings may be particularly burdensome, especially for physicians who are parents or who have additional demands from their personal lives.Therefore, in this study, we aim to measure the overall burden of tumor boards as well as the burden of early morning and/or late evening tumor board meetings, with the goal of identifying factors associated with greater physicianassessed burden.

Survey Formation
We developed an original survey instrument (eAppendix in Supplement 1) following the American Association for Public Opinion Research (AAPOR) guideline and checklist for reporting results of internet e-surveys. 7This survey instrument was not validated.This cross-sectional survey study was approved by the Cedars-Sinai Medical Center institutional review board.Participants provided written informed consent.

Survey Collection
The study population was drawn from practicing physicians involved in oncology care from hospitals and medical centers throughout the US.Participants were recruited by either (1) social media links posted on Twitter and Facebook, including Facebook groups for physician parents, or ( 2 Participants were informed that the survey's purpose was to better understand the administrative burden of multidisciplinary tumor boards.Respondents were provided an information sheet to review, and on agreeing to the terms and providing written informed consent, participants completed the survey via REDCap (Vanderbilt University) (REDCap survey instrument in eAppendix in Supplement 1).The survey was not pretested or validated.Only completed surveys were analyzed.

Tumor Board Start Times
Tumor board start times were independently collected (ie, not assessed by the REDCap survey instrument).Personal colleagues of the coauthors in radiation or medical oncology at National Cancer Institute (NCI)-designated cancer centers or US World and News Report top 40 hospitals for cancer were contacted individually by email from November 16, 2021, through January 3, 2022, to determine the start times of regularly scheduled multidisciplinary tumor board meetings.Early morning tumor board meeting start times were defined as occurring before 8 AM, while late evening tumor board meeting were defined as occurring at 5 PM or after.

Statistical Analysis
Data are presented as the number and percentage of respondents for categorical variables and as mean (SD) or median (IQR) values for continuous variables.The primary outcomes were the level of overall tumor board burden (TBB) and early or late TBB as measured on a scale of 1 to 4 (1, not at all burdensome; 2, slightly burdensome; 3, moderately burdensome; and 4, very burdensome) as reported by respondents.
Univariable and multivariable analyses of outcomes were carried out using the probabilistic index (PI) model, 8,9 where the PI is a measure associated with the Mann-Whitney test.The probability that an outcome value for one group is greater than or equal to the outcome value for another group was estimated, along with a Wald-type 95% CI.P values were calculated using Wald statistics.In PI model analyses, covariates with P < .10 on univariate analysis were included in multivariable analyses.In the multivariable analyses, multicollinearity was assessed by the variance inflation factor.Model fit was assessed as previously described. 10Analyses were performed using R, version 4.0.5 (R Project for Statistical Computing), 11 with 2-sided tests at a significance level of P < .05.Respondents' comments were visually summarized using word clouds, and inductive thematic analysis was performed.Analyses were performed using R, version 4.0.5 (pim, tm, and wordcloud libraries).

Characteristics of Respondents
In total, there were 111 complete surveys (of 117 initiated).The median age of respondents was 42 years (IQR, 36-50 years), with 52.3% of participants (n = 58) identifying as women and 42.3% (n = 47) as men (Table 1).Radiation oncology was the most common specialty reported (39.6% [n = 44]), although respondents came from all specialties, including medical oncology, surgery, radiology, and pathology.Although more than half of participants (56.8% [n = 63]) attended 1 to 2 hours of tumor boards per week, 41.4% (n = 46) attended 3 or more hours of tumor boards per week, and 58.6% (n = 65) attended 1 to 2 hours per week of early or late tumor boards (defined as starting before before 8 AM or at 5 PM or after).In addition to tumor boards, 55.0% of participants (n = 61) spent an additional 1 to 2 hours and 27.9% of participants (n = 31) an additional 3 or more hours per week on other departmental or multidisciplinary rounds, such as medical record rounds or contour rounds.Furthermore, nearly all respondents reported additional hours per week on other administrative work or meetings, with 29.7% (n = 33) spending 1 to 2 hours, 24.3% (n = 27) 3 to 4 hours, 19.8% (n = 22) 5 to 6 hours, and 24.3% (n = 27) more than 6 hours weekly on other administrative work or meetings.Only 8 respondents (7.2%) were provided any form of compensation for time attending tumor boards.Of these, the compensation types were monetary for 4 respondents, with 2 respondents each receiving relative value unit-based compensation or compensation built into salary expectations.Further demographic, employment, and administrative characteristic data from respondents are summarized in Table 1.

Qualitative Analysis of Respondent Comments
More than one-fourth of respondents (28.8% [n = 32]) provided comments.Thematic analysis of general respondent comments revealed 16 subthemes among 5 primary themes encompassing value or compensation (n = 10), feedback or gratitude (n = 10), administrative or scheduling (n = 7), wellness (n = 5), and family dynamics (n = 4) (Box).Specifically, 4 participants commented that their time preparing for the tumor boards was not valued, 3 participants noted that their time commitment in general was not valued, and 3 emphasized that their time was uncompensated,  displaced burden to spouse or partner (n = 6), disruption of mealtime or feeding or breastfeeding (n = 4), requirement for multitasking (for virtual tumor boards) (n = 3), disruption of bedtime (n = 2), and less time with children (n = 2).Specifically, regarding disruption of transportation and/or nanny or day care logistics, participants noted, "it is impossible to juggle," "makes day care drop-off impossible," "I can't pick up my kids," "hard to get childcare," or they must "carefully coordinate with partner's schedule."Within the theme of displaced burden to spouse or partner, 1 participant noted, "I'm unable to help.My wife manages drop-off and pickup," another that "my wife does all the work," while another commented that "it's an 'ask' of my husband that 'dings' our relationship and the balance of 'asks/gives.'"Word clouds summarizing the effect of tumor boards on childcare and feeding and sleep are shown in eFigure 1 in Supplement 1.

Discussion
In this survey study of TBB, identifying as a woman or parent was independently associated with increased burden from early or late tumor boards.Having 2 or more children, attending 3 or more hours per week of tumor boards, and radiology or pathology specialty were associated with a higher level of overall burden.Future strategies should aim to decrease the disparate burden on parents and women.Together, these results expand on prior research and add to the growing body of literature on workplace burden, physician wellness, and the burden on physician parents.
Several studies have shown that tumor boards are beneficial for patient management. 1,12,13This benefit requires multidisciplinary input because significant changes in management often occur from pathology, radiology, staging, and surgical clarifications. 14,15These findings are similarly observed at the global level, with a survey of oncologists from various Middle Eastern countries reporting that nearly all (93%) respondents agreed that tumor boards should be mandatory. 16Furthermore, in a a There were 111 observations used in the multivariable model.If PI is greater than 0.5, then the probability that the overall tumor board burden for B is greater than A is high, indicating that B has higher overall tumor board burden.If the PI is less than 0.5, then the probability that the overall tumor board burden for B is greater than A is low, indicating that A has higher overall tumor board burden.
b Comparison denotes the probability that overall tumor board burden for B is higher than that for A (reference level).
c A PI of 0.5 indicates no difference between comparisons (ie, A = B).
d Not included in the multivariable model.respondents reported that tumor boards provided an overall benefit to patients that was worth the time and effort.However, respondents also commonly wanted increased tumor board efficiency and a coordinator for case preparation. 17For pathologists and radiologists, considerable time is required to prepare cases (eg, review slides, microscopy, and images).Therefore, it not surprising that radiology or pathology specialty was associated with a higher level of TBB in this study.
Our study observed that attending 3 or more hours per week of tumor board was associated with a higher level of burden.Furthermore, 42.3% agreed that the number of tumor boards attended was associated with their professional burnout.Although this finding does not directly support an association between tumor board hours and burnout, it is consistent with data reporting that increased work hours, clerical burden, and stressful professional events have been associated with burnout in oncologists. 189][20] Furthermore, several respondents in this study commented about the association of tumor boards with their wellness and wellness activities.And while individual-focused interventions, such as resiliency training or self-care programs, have been shown to help with burnout, institution-based strategies that call for wider organizational change have demonstrated a significant reduction in burnout. 21The combination of individual and institutional interventions is more effective, with longer-lasting results than person-directed interventions. 19,22,23Further investigation of burnout, depersonalization, and derealization would allow for a deeper understanding of the association between TBB and burnout and is warranted.
Our finding that women and parents reported increased TBB from early or late tumor boards and commonly reported a negative association with family dynamics is consistent with growing data describing the challenges of physician parents striving for work-life balance.Work-home conflict is more prevalent among physicians aged 35 to 44 years and among those with long work hours 24 and is associated with burnout. 25,26Furthermore, a survey of women oncologists reported that the biggest sacrifice of an academic career was "time with loved ones." 27Related to this finding, another survey study of female oncologists revealed that two-thirds described long work hours and heavy workload as negatively associated with family planning, while one-third experienced pregnancy or maternity leave-related discrimination. 28Another survey of predominantly female physicians revealed that 56% regretted delay of childbearing, while those with fertility challenges were more ) email to Cedars-Sinai oncology physicians via listservs.Participants were invited to participate in a voluntary, anonymous survey.The survey was open to participation from March 3 through April 3, 2022.

Table 1 .
Demographic and Employment Characteristics (continued) 1 participant stating that they spend 3 to 6 hours preparing for tumor boards each week, "all uncompensated and unrecognized time."Five participants commented on the demand of early or late tumor boards or other meetings affecting their wellness and work-life balance, with 1 participant stating, "the main issue with meetings before 0800 or after 1700 is the impact [on their] ability to engage in [their] wellness activities, which has aided in prevent[ing] burnout."Two respondents commented specifically that recurring administrative meetings and tumor boards should not be before 0800 or after 1700, with 1 participant adding, "especially as these clinical activities are not compensated despite being critically important in the management of patient care."Five participants expressed gratitude for the study, with 1 participant commenting that the study was "asking the real questions for the future."Among 77 respondents who were parents, 18 (23.4%)provided comments about the association of early or late tumor boards with their children or family logistics.Thematic analysis revealed 6 themes, including disruption of transportation and/or nanny or day care logistics (n = 12), including

Table 2 .
Burden Level and Home Life Factor Characteristics a Includes responses only from those with children.

Table 3 .
Univariate and Multivariable Analyses of Level of Overall Tumor Board Burden a (continued)

Table 4 .
Univariate and Multivariable Analyses of Level of Early or Late Tumor Board Burden Downloaded From: https://jamanetwork.com/ on 11/06/2023 survey distributed to international American Society of Clinical Oncology members, nearly all

Table 4 .
Univariate and Multivariable Analyses of Level of Early or Late Tumor Board Burden a (continued) If PI is greater than 0.5, then probability that early or late tumor board burden for B is greater than A is high, indicating that B has higher early or late tumor board burden.If PI is less than 0.5, then probability that early or late tumor board burden for B is greater than A is low, indicating that A has higher early or late tumor board burden.Comparison A < B denotes the probability that early or late tumor board burden for B is higher than that for A (reference level).A total of 84 observations were used in the multivariable model.Two participants who responded "prefer not to answer" were excluded from analyses.34.A physician-only Q&A platform for expert answers to real world clinical questions.theMednet.Accessed September 12, 2023.https://www.themednet.org/35.Griffith M, Spies NC, Krysiak K, et al.CIViC is a community knowledgebase for expert crowdsourcing the clinical interpretation of variants in cancer.Nat Genet.2017;49(2):170-174.doi:10.1038/ng.377436.Wright AA, Katz IT.Beyond burnout-redesigning care to restore meaning and sanity for physicians.N Engl J Med. 2018;378(4):309-311. doi:10.1056/NEJMp171684537. Lawrence JA, Davis BA, Corbette T, Hill EV, Williams DR, Reede JY.Racial/ethnic differences in burnout: a systematic review.J Racial Ethn Health Disparities.2022;9(1):257-269.doi:10.1007/s40615-020-00950-0Word Clouds Summarizing the Most Frequently Encountered Respondent Comments Related to Early/ Late Tumor Boards Negatively Affecting (A) Childcare (e.g., Daycare, Nanny) or (B) Child Feeding (Including Direct and/or Indirect Breastfeeding) and/or Sleep Logistics eFigure 2. Tumor Board Start Times From 22 NCI-Designated Cancer Centers and/or U.S. World and News Report Top 40 Hospitals for Cancer eTable.Alphabetical Listing of National Cancer Institute-Designated Cancer Centers and/or U.S. World and News Report Top 40 Hospitals for Cancer From Which Tumor Board Start Times Were Collected eAppendix.Survey: Administrative Burden of Tumor Boards a b c d A PI of 0.5 indicates no difference between comparisons (ie, A = B).eNot included in the multivariable model.f